Authorization

Authorization

Moving Forward, PLC — Michele T. Cole, Ph.D., LCSW, 117 S. St. Asaph St., Alexandria, VA 22314, 571-483-0306
I authorize Moving Forward, PLC to keep my signature on file and charge my Visa, Mastercard, or Discover for psychotherapy sessions on the date of the session.
The following payment options are in place to keep your credit card information secure.*

1. Admin support will contact you directly for payment details to ensure the safety of your credit card information. Please make sure you are available as this should be collected prior to your session.2. Leave a voicemail with payment information on our secure confidential voicemail by reaching: 571-483-0306
Preferred contact information:*
If you would like to contact us directly please email us at: adminsupport@movingforwardplc.com

Thank you!
Patient Name*

First NameLast Name
Guardian Name (if patient is under 18)

First NameLast Name
Effective Date*

MonthDayYear
Date
Signature

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Thank You,
Michele T. Cole, Ph.D., LCSW
Director, Moving Forward, PLC
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